Multidisciplinary discussion of: Early staged NSCLC

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1 Multidisciplinary discussion of: Early staged NSCLC

2 2 different classes of patients Stage IIIA pt2pn2 Stage IIB pt3pn0

3 2 different classes of patients 50% 40% 30% 20% 10% 3y survival 50% 40% 30% 20% 10% 3y survival 0% 0% ct1-3n2m0 pt1-3pn2m0 ct3n0m0 pt3pn0m0 Stage IIIA T2N2 Stage IIB T3N0 Mountain CF, Chest, 1997, 1711

4 Early staged NSCLC the problems Tumour: T stage Radical resection? Risk of local relapse? Nodes: N stage Risk of distant metastases?

5 The Pancoast Tumour Case 1

6 Syndrome described by Pancoast in 1932: pain in shoulder and arm weakness in arm wasting of the muscles of the hand ipsilateral Horner syndrome lesion at the apex of the lung = superior sulcus tumour The Pancoast Tumour Pancoast HK: JAMA, 99, 1391, 1932

7 Symptoms / sings: Ipsilateral ptosis with narrowing of the palpebral fissure Miosis Enophthalmus Anhidrosis Mechanism: Involvement of the paravertebral sympathetic chain and the inferior cervical (stellate( stellate) ) ganglion Prevalence The Horner Syndrome Around 50% (14-83%)

8 The Neurologic Complications Symptoms / sings: Weakness and atrophy of the intrinsic muscles of the hand Paresthesia of the 4th and 5th digit and medial aspect of the arm and forearm Pain in shoulder,, arm Complications: Invasion of the intervertebral foramina (5%) = spinal cord compression and paraplegia. Ultimately,, 25% of pts develop spinal cord compression

9 Histology: Majority: squamous cell carcinomas Some: adenocarcinomas Rare: SCLC (5%) CAVE: Pathology Other malignant diseases: Mesothelioma, metastases, hemangiopericytoma, plasmocytoma Non-malignant diseases: Vascular aneurysmas Tbc, fungi Histological diagnosis is mandatory!!

10 Predictive / prognostic factors Poor prognostic factors Tumour stage Extension of the tumour into the base of the neck Invasion of the vertebral body / great vessel Involvement of the mediastinal lymph nodes Long interval until diagnosis Good prognostic factors Good PS Weight loss <5% Pain relief after initial treatment Radical resection

11 The Pancoast tumor: FACTS Incidence: rare: <5% of all primary NSCLC Stage usually: : T3-4, N0-1-(2) MRI for investigation of invasion of adjacent organs (vertebral body, brachial plexus.) MRI or CT brain: indicated before surgery 5y-survival is poor: : 20-30% depending on T/N- stage Standard of care is a multimodality therapy Farray D. et al., JCO, 14, 3257, 2005 Alifano M., et al., Chest, 124, 996, 2003 Rusch VW, et al., J. Thorac Cardiovasc Surg., 119, 1147, 2000

12 The Pancoast Tumour: the SWOG trial 9416 / INT 0160 Phase II trial: to test efficacy and tolerance of induction chemo/radiotherapy before surgery. Patients - untreated - T3-4N patients - 76 men/women - med. age: 56 y Induction therapy: - DDP: 50 mg/m 2 d1, 8, 29, 36 - VP-16: 50 mg/m 2, d1-5, Radiation: 45Gy 25 fractions Surgery: - of 88 pts operated: 94% compl. resection - ccr: 36% - 5y survival: 41% Space for improvement Rusch VW, et al., PASCO 22, 2003, abstract 2548, p634

13 The Pancoast Tumour Main objective: to evaluate safety and efficacy of MiViP CT/RT as induction therapy Patient inclusion criteria (T3-4 4 N0-1, ipsilat. supracl.): NSCLC with invasion of the first rib and the superior chest wall Ipsilateral supraclavicular node included,, but N2 excluded JCOG 9806 Induction therapy CT: Mitomycin C (8 mg/m 2 ), Vindesine (3 mg/m 2 ), Cisplatin (80 mg/m 2 ), q28, 2 cycles RT: 45 Gy in 27 fractions (concomitant with CT) Surgery: : days after RT+CT Suzuki K. et al. Barcelona, P049

14 The Pancoast Tumour: the SWOG and JCOG trials N patients Age (years( years,, med.) Gender (M/F) PS (0 / 1) T3 / T4 Hist. (Ad/Sq Sq/others) N0 / N1 / N3 JCOG % / 12% 40% / 60% 84% / 16% 45% / 36% / 19% 84% / 12% / 4% SWOG % / 31% NR* 71% / 29% NR* NR* * Not reported WCLC, Suzuki et al., Lung Cancer, P049, 2006 Rusch VW, et al., PASCO 22, 2003, abstract 2548, p634

15 The Pancoast Tumour: the SWOG and JCOG trials % of patients Pts y JCOG SWOG y Total patient Operated Complete resected pcr Postop. mortality Survival rate

16 Conclusions and open questions If no metastatic disease: Concurrent chemoradiotherapy followed by surgery (if no progression) Choice of chemo-radiotherapy Concurrent thoracic radiotherapy (45 Gy) Chemotherapy: cisplatin doublet (vinorelbine( vinorelbine, etoposide ) Surgery: 3-5 weeks after completion of CT-RT Postoperative therapy? No data for adjuvant chemotherapy (if pn1-2 disease) Farray D. et al., JCO, 14, 3257, 2005 Alifano M., et al., Chest, 124, 996, 2003 Rusch VW, et al., J. Thorac Cardiovasc Surg., 119, 1147, 2000

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